Carroll Health and Rehab LLC

In the surveyor’s words

From the most serious findings on record at Carroll Health and Rehab LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 28, 2025

  I. Based on observation, record reviews and interviews the facility failed to have an adequate system in place to ensure residents at risk for elopement are supervised to prevent elopement from the facility for 1 (#73) of 3 (#8, #72, and #73) residents reviewed for elopement. The deficient practice resulted in an Immediate Jeopardy for Resident #73 on 07/21/2025. Resident #73 was last observed on 07/21/2025 at 9:51 p.m. Resident #73 was picked up by police on 07/22/2025 at 6:28 a.m. after being notified of Resident #73 pacing on the four-lane highway approximately 0.9 miles from the facility. The police returned Resident #73 to the facility on [DATE] at 6:52 a.m. without injury. Resident #73 exited the building through a window in his room. […]

• Immediate jeopardy, isolatedF835Jul 28, 2025

  Based on record reviews and interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #73) of 3 (#8, #72 and #73) sampled residents reviewed for elopement. S3Director of Nursing (DON) failed to 1) notify staff that Resident #73 was assessed to be at risk for elopement and 2) initiate the interim care plan with appropriate interventions to prevent elopement after S3DON assessed Resident #73 to be at risk for elopement.The deficient practice resulted in an Immediate Jeopardy for Resident #73 on 07/21/2025. Resident #73 was last observed on 07/21/2025 at 9:51 p.m. […]

• No harm, potential for more than minimal, widespreadF725Jul 28, 2025

  Based on record review and interview, the facility failed to ensure there was sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services. The facility had: 1) excessively low weekend staff during Fiscal Year Quarter 2 2025 dated 01/01/2025 to 03/31/2025 and 2) insufficient staff on: 06/08/2025, 06/14/2025, 06/22/2025, and 06/28/2025.Findings:Review of the facility's Payroll-Based Journal (PB&J) Staffing Report revealed the facility triggered excessively low weekend staff for Fiscal Year Quarter 2 2025 dated 01/01/2025 to 03/31/2025.Review of the facility's January 2025 weekend personnel staffing pattern revealed insufficient staff for the following dates: 01/04/2025, 01/05/2025, 01/11/2025, 01/12/2025, 01/18/2025, 01/19/2025,… […]

• No harm, potential for more than minimal, patternF568Jul 28, 2025

  Based on interview and record review, the facility failed to ensure that individual financial records are available to the resident through quarterly statements for 1 (#6) of 1 (#6) residents reviewed for personal funds out of a total sample of 37 residents. Findings:Review of the facility's Resident Funds policy (undated) revealed in part:Purpose: Ensure than an individual record is established for each resident on which only those transactions involving his/her personal funds are recorded and maintained. Procedure:3. The individual financial record must be available to the resident through quarterly statements and upon request. […]

• No harm, potential for more than minimal, patternF584Jul 28, 2025

  Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 4 (#1, #2, #22, #43) of 6 (#1, #2, #6, #22, #40, #43) sampled residents reviewed for environmental concerns. The facility failed to ensure that residents' wheelchairs were maintained in good repair.Findings: Resident #1 Review of Resident #1's record revealed he was admitted to the facility on [DATE] with diagnoses including acquired absence of left leg below knee, Type 2 diabetes, and epilepsy. […]